Injuries and x-rays

Summer has a lot of injuries, which makes a nice change from cold and flu season, except of coarse for the patient. When should you take your kid to get an x-ray of their injury? General speaking; pin point pain is more likely a fracture whereas pain over an area is most likely not. Wrists are much more likely to be fractured then ankles. Twisted ankles nine times out of ten are not fractured, but pin point wrist pain 9 times out of ten is a fracture. If your child can walk on their twisted ankle it is most likely not broken. Twisted ankles hurt below the lateral malleolous, the bone on the outside of the ankle. Pain over the bone or further up the leg is more concerning for a fracture. Most sprains should be improving in 2-3 days, if they are not please come get an x-ray. I have seen recently dislocations and fractures that are 2 weeks old. It's much easier to treat those early on and cheaper to boot.

We treat fractures in the acute setting most of the time with a splint. We don't cast right away. Most of the time there is swelling within the first few days of the injury. The swelling needs to subside before a cast is placed.
The initial treatment for any injury should be ice and ibuprofen and compression if available. A fracture has to heel on its own, the cast is simply there to hold the bone in place while it repairs.

Thoughts, doctors and patients

I was encourage by a friend today to blog about my current situation. I was diagnosed on pathology, meaning on examination of the tissue, after my thyroglossal duct cyst removal with papillary carcinoma. Thyroid cancer. I have since had a partial neck dissection and removal of my thyroid. I had 2 lymph nodes with cancer involvement.

People ask me if it is better or worse to be a doctor and go through this; my answer is both. I see a lot of bad things happen to people, it's just the nature of the job. I figure, pessimistically of coarse, that bad things happen to everyone. So when the call came my first thought was "well this is my bad thing", but then my next thought is "wait, that's cancer!". When I went to have an ultrasound of my neck to see if there was anything more involvement then the tissue already removed, the instant I saw the big lymph node on the screen, I started to get scared. When the endocrinologist who did the procedure looked at tissue from the lymph node and declared it thyroid tissue, everyone in the room knew that it was cancer, she didn't have to say it, there is no other reason for thyroid tissue to be in a lymph node other then cancer. My family kept saying "so when you get the results back you'll know" While it's true that we were waiting for official results from the pathologist, I knew it wasn't going to change anything. That's the problem with being a doctor, you can't shield the patient.

The good part is while it still is scary that I have thyroid cancer, it could be a lot worse. Not all cancers are created equal, some are a lllllooooottttt worse then others. Papillary carcinoma, as far as things go, is really on the good side of things. It's hard to explain to those around me that "I'm going to be fine" really means "I'm going to be fine". I say that with all of the medical statistics behind me. Papillary carcinoma has a 99% 20 year survival rate. That is fantastic. I will still have to constantly be checked to see if it is recurring, but really I'm going to be fine. I know that but those around me don't necessarily understand it and look at me like I'm dying.

Still it was very helpful when a college shared his personal experience with a different type of cancer, he didn't offer any advise, just shared. It's hard not to know what I want people to say and I'm sure it's hard to not know what to say.

Chicken Little Flu

H1N1 is everywhere. About 50% of what I am currently seeing in clinic is most likely swine flu. It amazes me how freaked out people are about this pandemic. I've started calling it the chicken little flu because evidently the sky is falling. Most people are no more sick than from the normal flu. It's just at an odd time of year. H1N1 is so prevalent now that we no longer test for it. If it looks like a duck, quacks like a duck or is it a pig in this case? The best way to prevent flu is lots of good hand washing and basically not letting people cough or sneeze on you. If you are sick you don't necessarily need to go to the doctor unless you are getting worse or not improving. Secondary infections from the flu are not unusual following flu the most common being ear infections and pneumonia. Every year people die from flu. This is really not any different. Most otherwise healthy people are not at risk from dying from H1N1. Tamiflu, which is an antiviral, mostly helps you not be contagious to other people. Mostly we are using it in high risk groups or hospitalized patients. Try not to freak out about swine flu, just wash your hands and stay away from sick people, I personally have a hard time with that last one.

My Adventures as a Patient

Recently I had my thyroglossal duct cyst removed. It is an embryological remnent of head and neck developement that should have closed off but in some people like me persisted as a potential space. I first noticed a lump on my neck about 4 years ago, but when I look at pictures it has been there longer then that. I'm sure I made the ENT's day when I walked into his clinic and said I wanted it out and had already done all the workup.

That being said, doctors make horrible patients. I told the aide taking my tempurature that she had done it wrong and had bounced off the wall instead of the tympanic membrane. My husband says "Stop being a doctor." I didn't tell them again when they were doing it wrong, but I did argue with the anesthesiologist about breastfeeding and general anesthesia. I had researched it and post-op pain control. He did put me to sleep kinda fast. After the surgery when I asked for pain and there was no order for what I wanted I made the nursing staff call and get it ordered. I kept dumping the output(urine) after noting how much and then would just tell the nursing staff, finally they brought me the sheet to chart input and output. The computure in the room to track medication kept spinning up and down so I put it on standby. I made them turn down my IV without an order because I was having some much output. I stripped my own JP drain. I made them take out my IV without an order and told them how to bandage my wounds. I am sure the nursing staff was very happy to have me go home.

Ear infections-- drugs

Sorry for infrequent blogging, evidently when I say tomorrow, I actually mean next week. I blog at work if not too busy, and lately it's been so busy I don't eat. Trying to blog at home is too much of a headache for me with children, hats off to all of you who accomplish that feat. On to ear infectons.

There are three major organisms that can cause ear infection. We usually start with high dose Amoxicillin for ear infections. Sometimes the bacteria have mechanisms in place to defend against the antibiotics we give. Augmentin, which is usually the next step, is amoxicillin plus a drug to fight the bacteria's defense mechanism. Omnicef, which is often the third choice, is a broad spectrum antibiotic. It's like a big missile that wipes out everything in its path. Amoxicillin is not a weak antibiotic anymore then Omnicef is a strong antibiotic. Amoxicillin is a great drug, but more specific like a precision missile that only wipes out a few buildings instead of a whole block. Any antibiotic can cause diarrhea and these often do. Taking some probiotics like lactobacillus when on antibiotics can help. Usually if your child has not been on any antibiotics for at least 2 months we start with amoxicillin again. The bacteria usually have to be exposed to the drug to be resistant to it. We want to use the antibiotic with the most narrow spectrum to cover the infection, because if we keep giving the broad spectrum drugs and your child's infection become resistant to that drug, there are fewer antibiotic choices left and a higher likelihood that your child could have complications with other resistant bacteria. Some children do seem to be colonized with resistant bacteria for whom amoxicillin no longer is effective, but for the most part always start with amoxicillin, excepting of course those who are penicillin allergic.

Ear infection

Ear infections are a secondary infection that usually occur after an upper respiratory tract infection ( runny nose, congestion and cough). Most often your child has been sick for a bit, starts to get better and then develops fever and stops eating or sleeping much. Fluid that has built up in the Eustachian tube gets secondarily infected. Recently there have been a lot of studies in Europe where they actually tap the infected ear and grow them out and they have found that especially in older children, the vast majority of unilateral ear infection without fever are viral. In the realm of 75-80% of them. In children older then 2 without fever and a one sided ear infection I give the parents a script for an antibiotic and tell them to wait a couple of days to see what happens. I recommend the parents continue to treat their child's pain with Tylenol and ibuprofen and I really like the benzacaine numbing drops. I even do this with my own children. I have looked in their ears and they have bad infection I given them pain meds and send them to bed and then they never complain about it again.

In children less then 2 I treat all infections.
More about ear infections tomorrow.

Why can't they be like that at home?

Wednesday morning I barely get home from dropping the kids off at school and the phone rings. It's the school. "Mommy, I forgot to tell you last night, I'm out of lunch money and my teacher said I have to call. " Also my son couldn't find his gloves and has taken the good ones to school which I only like him to use for skiing. After morning naps and finding the other gloves I pack up the two youngest and go to school. After dropping off the money for lunch, I go to my son's classroom and find he is currently at lunch. He begs me to stay, so I buy Imogen a lunch. My oldest's class comes while we are sitting there and she and here friends sit with us too. They are all so excited to sit together. After a bit my son show his 4 year old sister where to take her tray and then leads her by the hand out to recess. When I catch up with them, he is trying his hardest to lift her onto the swing. He only weighs 5 lbs more then she does, so is not very successful. Once I lift her on he insists on pushing her and then takes her up the slide and reassures her that it's not too scary and even defends her against kids who just want to push her down the slide because she is holding up the line. They were both sad when he had to go back to his class. These of coarse are my same two children who fight about everything when they are home.

It's heeerrrre!!!!

Those three little letters that strike fear in the heart of parents everywhere are here: RSV. Bronchiolitis which is the symptoms that RSV can often cause come around every winter. Usual symptoms include breathing fast, having lots of nasal secretions, wheezing and decreased appetite. Lots of different viruses can cause bronchiolitis, but RSV is the most common. You or older children can have RSV but have basic cold-type symptoms, in young babies it can be much worse. Bronchiolitis is definitely a spectrum, you can be just a little bit more sick then your normal cold or really bad and need to be in the hospital. How bad your child's symptoms are can change at anytime. Bronchiolitis symptoms can last up to a month. Antibiotics do not help the symptoms of bronchiolitis. The best thing to do is keep a humidifier going in the room the child spends the most time 24 hours a day. I recommend cool mist, the warm mist humidifiers are fabulous breeding grounds for bacteria. I recently heard something from a patient about the cool mist humidifier will make the room too cold and make kids sick. That is not true. The other thing to do is nasal saline spray and suctioning. I give my own kids a squirt of saline and suck them out with the blue suction bulb whenever they are having a hard time sleeping or eating because they are congested. There is not medication that is safe in young children to make congestion go away. I know they hate being sucked out. I know they cry like you're trying to kill them. Do it anyway. Do use gentle suctioning, don't do it so hard that they are bleeding.

Good reasons to see the doctor:
1. Your child is breathing faster then 60 times a minute if less then 1 or greater then 40 times a minute if greater then 1. Take off their shirt and watch their chest for a full minute and count. Don't count for 15 seconds and multiply. Best to count when they are as calm as possible.
2. They are having more nasal secretions then you can handle with the bulb suctioning. I know around where I live there are several respiratory clinics in hospitals that are open around the clock where you can take your child to be deep suctioned if needed. Ask you doctor. The clinics most likely need an order first.
3. Your child has any signs of dehydration; making less then 2-3 good wet diapers a day, not making tears when they cry, when you look in their mouth it is tacky instead of moist.
4. They are having any signs of respiratory distress. Flaring their nostrils when they breathing, using their stomach muscles to breath or pulling in between their ribs with breathing, otherwise known as retractions.

The beginnings of adolescence

Last Sunday after my oldest, Giselle, gets out of the shower. She is normally my very obedient, helpful, no attitude child. I tell her she needs to blow dry her hair before going to church. " But I don't like to blow dry my hair!" "Well I'll do it" I say. She protests loudly, so I say, "If you want to have the stacked hair cut, you have to blow dry it." She says "I didn't want my hair cut like this, you made me get it" "What did I say when they asked me how I wanted your hair cut? However she wants it, it is her hair." "Oh" she says. 1 point for mom. She tries again. "I didn't want to take a shower this morning, you told me I had to." " No honey, what I said was, 'If you are going to take a shower this morning you should probably do so, so that you have enough time.'" another "oh".

Hopefully this is not a pattern of things to come, but I dare say it probably is. And thank you to whomever invented the stacked bob haircut that has to be blowed dried or it looks awful.

I torture small children

My life became a lot easier the day I realized my job is to torture small children. I was the supervising resident one evening when I was called down to the Emergency Department for a consult on a 5 year old with alteration of consciousness and fever. The patient had been at school when it was observed that he was lethargic ( see previous post) and febrile (fancy for has a fever). The patient had been seen by the resident in ED and had had blood work, urine and spinal tap and a CT scan (CAT scan), all of which were normal. I went to look at the patient and really had to fight him, he was no longer lethargic, to get a good look at his ears and throat. Mom was not happy with me because she didn't want me to hurt him and did not assist at all with holding him still for the exam. His throat was nasty looking. I swabbed him and went to talk to the resident who had already seen him. I asked her what she thought of his throat and she said " Well I didn't get a good look at it because the mom was upset." The patient's strep came back positive. Here's what happened: The patient had a febrile seizure that was not witnessed and then was post-ictal. After seizures people are usually quite out of it. The poor kid had been put through a whole battery of tests for something really quite simple. I concluded that my job was to make sure I got a good look at kids ears and throats regardless of how mad I make a parent. Especially in pediatrics a lot of infections are in the upper respiratory tract. I don't try to hurt kids and I try to make the exam as fast and fun as possible, but my job is essentially to torture small children.

But he's got white stuff in his throat.

Currently we are seeing a lot of strep going around. It is most of the time a very easy diagnosis and treatment. I tell my MA she gets a raise everytime she has a postive strep. Of coarse I have actually nothing to do with her salary, but it makes her happy. Beta-hemolytic Group A Strep (Strep throat) is treated with antibiotics for one purpose; to prevent Rheumatic Heart Disease. Sorry, but you feeling better pretty fast is just a added bonus. There are other bacteria that sometimes come back postive on throat culture but they don't cause Rheumatic Heart Disease and usually they are not treated. There is some evidence that Group C strep and a couple of other "groups" might also need antibiotics so if it one of those it is treated. Contrary to popular belief exudate or white stuff on the tonsils are not very consistant with strep. They are alot more consistant with adenoid virus which is very good at mimicking strep. Having petechia on the soft palate and tonsilar pillars, the skin in front of the tonsils, is more consistant with strep. Usually cough and runny nose do not accompany strep. Sometimes people have headache and stomachache. Unless you have a strep rash the only way me or any doctor can tell if you have strep is to do a rapid strep antigen test or culture. The rapid test is about 93% accurate which is remarakably good as far as rapid tests go.